Mystery Diagnosis (transcript)

(ANNOUNCER)       
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally-operated and community-based Blue Cross and Blue Shield companies, supporting solutions that make safe, quality, affordable healthcare available to all Americans. 

(ANNOUNCER)       
Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.

(MUSIC)  

(DR. PETER SALGO)
Welcome to Second Opinion, where you get to see firsthand how some of the country’s leading healthcare professionals tackle health issues that are important to you.  Now each week our studio guests are put on the spot with medical cases based on real life experiences, more so today than usual, you’ll see why. By the end of the program, you’re going to learn the outcome of this week’s case and you’ll be better able to take charge of your own healthcare. I’m your host, I’m dr. peter Salgo and today our panel includes special guests Betty and Alan Dale, Dr. Ralph Jósefowicz, our second opinion primary care physician, Dr. Lisa Harris, and Dr. Alan Dengiz from the University of Michigan. Today, we’re going to try something different. We’ve invited two long time viewers, Betty and Alan Dale, your taste in television is excellent by the way, to join us and to share their case with us. We’re going to put our doctor’s diagnostic skills to work here. Betty, Alan, and I know the diagnosis, nobody else here does. Alright, four years ago you were enjoying your retired years. You were healthy, walking every day, you were staying active. Then what happened?

(BETTY DALE)
Well my first problem was I had started to stagger, my legs didn’t seem like they were going to hold me up. I began my walk; my gait was beginning to suffer. I suddenly realized I wasn’t enjoying walking any longer. 

(DR. PETER SALGO)
And how old were you at that time?

(BETTY DALE)
Eighty-three. 

(DR. PETER SALGO)
Alan, what did you notice?

(ALAN DALE)
There was a, a sign really in the house, quite apart from the outside, of shuffling. She was not picking up her feet. Sorry babe. That’s one of the first signs to me that all’s not well and we couldn’t figure out what it was.

(DR. PETER SALGO)
Lisa, what are you thinking now? 

(DR. LISA HARRIS)
You had no previous medical problems at all? You were not on medications or supplements? 

(BETTY DALE)
Right, right.

 (DR. LISA HARRIS)
And you were walking every day, for about how far did you walk daily?

(BETTY DALE)
Are you talking normally?

(DR. LISA HARRIS)
Yeah, normally. 

(BETTY DALE)
It was about two miles. There was a lovely farm near where we lived. We used to walk out to the farm to see the piggies. I was beginning to want not to go so far. 

(DR. LISA HARRIS)
So gradually you noticed that it was bothering you. Was it painful to walk? 

(BETTY DALE)
I would say it was more tiring, the effort of lifting up my feet. 

(DR. LISA HARRIS)
And had you noticed, Alan, if she had difficulty getting up out of a chair, or getting in and out of the bathtub? 

(ALAN DALE)
The first step was always a difficult one. Moving the foot the first time and then getting in to a rhythm of walking was always difficult at the beginning. 

(DR. LISA HARRIS)
So of course my mind is going to neurodegenerative disorders, Parkinson’s disease, things intrinsic to the muscle, calcium disorders. There is a whole laundry list of things that we need to work through. 

(DR. PETER SALGO)
But that’s initially what’s going through your mind. Gentlemen, feel free to join in. 

(DR. ALAN  DENGIZ)
Sure, I was wondering if you were having any pain in your neck or your lower back or anything like that? 

(BETTY DALE)
No, it was just the legs. 

(DR. PETER SALGO)
Why did you ask that?  

(DR. ALAN DENGIZ)
Well, there might have been some sort of a spinal disorder that was going on that could be impinging on nerve roots that might ultimately have caused these symptoms.

(DR. PETER SALGO)
So the nerves going to the legs? 

(DR. RALPH JÓSEFOWICZ)
The way I like to think about these things just with the history you gave us, the gradual onset of problems walking, shuffling, picking up the feet, you start first is it neurologic or non-neurologic? Could it be an orthopedic problem? Musculoskeletal? That’s why Lisa asked about the pain, usually orthopedic problems, musculoskeletal problems have pain. If it’s not that then you think of neurologically and as a neurologist they always like to localize the lesion. They like to start peripherally. Is it something involving the muscle? Well if it’s just the legs it’s more unlikely to be just muscle because then the arms would also be involved. It could be something involving the peripheral nerves and certainly neuropathies do begin in the lower limbs.

(DR. PETER SALGO)
Neuropathies are diseases of...

(DR. ALAN DENGIZ)
The peripheral nerves. 

(DR. LISA HARRIS)
And certainly before we refer her to a neurologist, as a primary care physician I would like to look at more generic things like thyroid disease which is very common in older people, vitamin D deficiency, calcium, metabolism issues, and stuff like that.

(DR. PETER SALGO)
That’s a long, long laundry list. 

(DR. LISA HARRIS)
Yes. 

(DR. PETER SALGO)
As we often say in medicine, the history is often 90% of the diagnosis. So tell us a little bit more? 

(BETTY DALE)
The memory was getting bad but you know I was eighty-three then and started to think, well, that’s because I’m an old lady, but my fellow comrades weren’t in that state and they all were older than I was. Alan used to get irritated with me and I used to…

(DR. PETER SALGO)
You should see his face when you say that. Alan, were you irritated with her and why? 

(ALAN DALE)
Well, she might ask me something and I would tell her and five minutes later, same question. I found that irritating, I guess but probably I’m an impatient person. 

(DR. PETER SALGO)
Were there any other subtle things going on? Your memory, anything else?

(BETTY DALE)
Well I began to get incontinent which wasn’t very nice. 

(DR. PETER SALGO)
Okay, let’s stop there. Anything else with your memory, word finding, anything? Help me?

(BETTY DALE)
I would go all around it trying to find a word that would do for what I was trying to say because I couldn’t come up with it, get the correct word. 

(DR. ALAN DENGIZ)
This happened, the memory started happening fairly quickly I take it? Is that correct? 

(BETTY DALE)
Yes. 

(DR. ALAN DENGIZ)
I think that’s a very important point because often times older adults will chalk something like that up to Alzheimer’s disease or some other normal sign of aging but definitely when it occurs that quickly it’s not going to be a normal part of aging and it’s not likely to be Alzheimer’s disease. Obviously you’ve got several different things going on at the same time, and so then we would have to do a fairly good evaluation both of you physically and laboratory testing.

(DR. RALPH JÓSEFOWICZ)
Betty, tell me more about this problem with the walking? What was the problem like? 

(BETTY DALE)
It was just I couldn’t keep up with Alan and I would not go in a straight path. I was beginning to wobble. 

(DR. RALPH JÓSEFOWICZ)
The problems with the walking, starting to walk, and then I think you mentioned that lifting one foot up was difficult.

(ALAN DALE)
In the house. 

(DR. RALPH JÓSEFOWICZ)
Right, in the house. 

(ALAN DALE)
I’d see it in the house and what Betty is talking about it was quite right. When she got out of the house she was having difficulty walking but just that first step seemed to be extremely difficult.

(DR. PETER SALGO)
Well why is that important to you?

(DR. RALPH JÓSEFOWICZ)
It’s important because the two things I’d be thinking about would be Parkinson’s disease or Parkinsonism and a condition called normal pressure hydrocephalus which is another condition that causes what we call a glue-footed gait, magnetic gait, or gait ignition failure. These are the three terms we use.

(DR. PETER SALGO)
So now they have a differential, she has a whole list of things including thyroid and vitamin D and calcium, and he’s got some neurologic stuff. And I heard you mention something just before I didn’t let you give them more information.

(LAUGHING)

(DR. PETER SALGO)
About incontinence.

(BETTY DALE)
Well I wet my knickers. I don’t know what else you can call it. 

(DR. PETER SALGO)
Why is it that when you say it with a British accent it sounds so much more dignified than it was? 

(LAUGHING) 

(BETTY DALE)
It’s a very undignified thing to happen. 

(DR. PETER SALGO)
Does this add to your differential? 

(DR. RALPH JÓSEFOWICZ)
Yeah.

(DR. ALAN DENGIZ)
Yes, very much so, but Betty can you tell me over what period of time this occurred? Do you recall? Was this over a matter of weeks or months?

(BETTY DALE)
Well I sought, I went to, started going to a doctor to see what they could do and it was rather unfortunate I told the doctor that my brother had died from Parkinson’s. As soon as they heard Parkinson’s they’ve said we’ve got it, we’ve got it, that’s her problem. 

(DR. PETER SALGO)
Now tell me a little bit about, if I may, I’m going to move the story forward. You went to your primary care doctor finally. 

(BETTY DALE)
Right. 

(DR. PETER SALGO)
Was there another clinic you went to also because you were complaining of your gait? 

(BETTY DALE)
Yes. Right. 

(ALAN DALE)
The Parkinson’s clinic. 

(BETTY DALE)
I spent, wasted a lot of time seeing a Parkinson’s doctor.

(DR. RALPH JÓSEFOWICZ)
What’s wrong with Parkinson’s here is two things; first of all you mentioned family history but 95% of patients with Parkinson’s don’t have a family history. The second thing is although in the very end of, the late stages of Parkinson’s disease, we’re talking ten years out, there could be some memory problems, but in your case you developed the memory problems very quickly.

(DR. LISA HARRIS)
Very rapidly

(DR. RALPH JÓSEFOWICZ)
And that would make Parkinson’s most unlikely.

(DR. PETER SALGO)
Because you went to the Parkinson’s clinic, they worked you up… 

(BETTY DALE)
Yes 

(DR. PETER SALGO)
…did a lot of tests, did you have Parkinson’s?

(BETTY DALE)
I don’t have Parkinson’s.

(DR. PETER SALGO)
Would it be considered normal, because you brought this up, for an eighty-three year old woman to have memory issues, walking issues, incontinence issues simply as a consequence of being eighty-three.

(DR. LISA HARRIS)
That was something I want to jump in. Aging is not associated with disease. It’s what your lifestyle has been prior to that. We can’t assume that because people have gotten older that they’re going to be ill. So no, just because she happened to be eighty, and she mentioned that her comrades weren’t having the same difficulties. This is a very rapid onset in someone who was previously healthy, something’s wrong.

(DR. ALAN DENGIZ)
Unfortunately, too many doctors will attribute these things to aging and will not take the time to do a proper diagnosis. 

(DR. PETER SALGO)
So let me see if I can now sort of place us in time. You’ve had the onset of symptoms; you went to your primary care. I know somebody looked at your gait, you went to a Parkinson’s clinic, now you know what you don’t have. Were you frustrated at that point because you don’t know what you do have?

(BETTY DALE)
Oh I was terribly frustrated and it was quite a while before they decided I definitely did not have Parkinson’s so I was given different medications, come back in three months. This went on and on for about a year. 

(DR. PETER SALGO)
Al, you’re a bystander here, you don’t have these symptoms but you’ve observed them. You’ve gone with her to the doctors. 

(ALAN DALE)
I have and I’m worried that everyone keeps telling her that she’s normal. All these tests, well no we can’t find anything wrong, you’re ok. 

(DR. PETER SALGO)
What’s in your differential? 

(BETTY DALE)
My lips are sealed. 

(DR. LISA HARRIS)
Normal pressure hydrocephalus. 

(DR. PETER SALGO)
Normal pressure hydrocephalus, what else? 

(DR. LISA HARRIS)
That’s pretty much at the top of my list. 

(DR. PETER SALGO)
And yours? 

(DR. RALPH JÓSEFOWICZ)
That’s it. 

(DR. PETER SALGO)
And yours? 

(DR. ALAN DENGIZ)
Absolutely, that’s it. 

(DR. PETER SALGO)
Alright, what happened next? I believe you told me you had a TIA a transient instemic Attack, something that looked like stroke but really wasn’t. You go to the hospital, they do a complete work-up there and they do a CT scan of your head. Which brings up the question, with all of these neurologic issues, had you ever had one before? 

(BETTY DALE)
No. 

(DR. PETER SALGO)
That was it, the first one? And what did that scan show?

(ALAN DALE)
It showed enlargement of the ventricles. 

(DR. PETER SALGO)
Enlargement of the ventricles. Now we’ve discussed ventricles on this broadcast before but usually in context with the heart, where there are chambers in the heart. But they did a scan of your head, and the brain has ventricles too? 

(DR. LISA HARRIS)
Yes. 

(DR. RALPH JÓSEFOWICZ)
Right, the brain has four ventricles and that’s where the spinal fluid is located. In Parkinson’s disease typically the imaging of the brain is normal. MR or CT scan in Parkinson’s disease doesn’t reveal anything and it’s not part of the typical work up. But for this condition that we’re all considering, normal pressure hydrocephalus, the ventricles are enlarged. 

(DR. PETER SALGO)
Would you have scanned her? 

(DR. LISA HARRIS)
Yes. Absolutely. 

(DR. ALAN DENGIZ)
Well, with the symptoms that she was having I definitely would have because Parkinson’s disease just didn’t make sense with the sudden memory loss and also with the incontinence. 

(DR. LISA HARRIS)
And the misfortune about this is that they didn’t need to spend as much time as they did in making the diagnosis. 

(DR. PETER SALGO)
We do have a scan much like yours, it isn’t yours, but would be typical of what someone with your diagnosis would have. Ok, this would be, a normal brain. The ventricles are those, the sort of slipper shaped things in the middle, they’re nice and thin, right? Now let’s see if we can advance this. 

(DR. RALPH JÓSEFOWICZ)
What you basically see is the ventricles are enlarged and it’s out of proportion to atrophy of the cortex which is the outside lining of the brain. When individuals get older, the brain does shrink a little bit, however, the shrinkage is very symmetrical with both on the inside and on the outside. What’s unusual here in this scan is that the ventricles are enlarged out of proportion to what you would expect to see with the atrophy of the shrinkage of the outside of the brain. This is called hydrocephalus and hydrocephalus in laments terms means water on the brain and in a case like this it means there is a blockage someplace because normally spinal fluid is made in the ventricles, then it percolates through the brain. It leaves the brain through these openings called foramina and then it goes to surround the brain on the outside and the spinal cord and then it gets absorbed in what are called the arachnoid granulations which are basically one-way valves in to the veins of the brain and then it goes back in to the heart.

(DR. PETER SALGO)
So, all at once panel, I think you’ve come to the same conclusion. 

(DR. PETER SALGO)
Don’t answer just yet. What was her problem? 

(ALL)
Normal pressure hydrocephalus. 

(DR. PETER SALGO)
And now you may, he’s applauding. Were they right? 

(BETTY DALE)
Am I supposed to say yes?  

(LAUGHING)

(BETTY DALE)
Yes, that was too easy for them, I think. 

(DR. ALAN DENGIZ)
If this is normal pressure hydrocephalus which wouldn’t necessarily have an obstruction for the cause of this. Was there an obstruction or was it truly normal pressure hydrocephalus?

(BETTY DALE)
I wasn’t told there was any obstruction. 

(DR. PETER SALGO)
The question I think on the table is why is there this fluid, this water, in the brain? What does it do? 

(DR. ALAN DENGIZ)
It’s sort of a shock absorber for one thing, plus the brain and the spinal cord has to be bathed in fluid so that’s really why we’re producing this. With normal pressure hydrocephalus what’s happening is you’re having an overproduction without the ability of those granules to take up the amount of fluid that you’re producing.

(DR. LISA HARRIS)
Right. 

(DR. RALPH JÓSEFOWICZ)
Yeah, the cause of this condition is unknown. There are secondary causes of your condition so for example, in a small percentage of patients some of them may have a head trauma, or they might have had meningitis, or a bleeding subarachnoid hemorrhage. But normal patients have none of this. 

(DR. PETER SALGO)
Very quickly, who gets normal pressure hydrocephalus? Can we abbreviate it occasionally, NPH? 

(DR. ALAN DENGIZ)
NPH. 

(DR. RALPH JÓSEFOWICZ)
NPH, older people. 

(DR. PETER SALGO)
Typically older, older meaning? 

(DR. RALPH JÓSEFOWICZ)
Seventies, eighties. 

(DR. PETER SALGO)
Ok. 

(DR. ALAN DENGIZ)
But I’ve seen it younger people than that as of well, when there wasn’t an obstruction so it was truly normal pressure hydrocephalus. 

(DR. PETER SALGO)
And there’s a triad of symptoms? 

(DR. RALPH JÓSEFOWICZ)
Right, it’s a, the triad is memory loss, and I call it sort of, it’s so not a dementia but a slowness of processing. The second thing you have is the gait problem and we call it gait apraxia. Apraxia basically means it’s a problem initiating the gait as I mentioned, sort of starting to walk, putting one foot in front of the other. When you’re sitting you can move your legs fine, the strength is perfectly normal, sensation is normal, but when you get up you sort of forget how to walk. And the third thing is urinary incontinence so the combination of the memory problem, the urinary incontinence and the gait problem. Some people say it’s wet, wacky, and wobbly.

(LAUGHING)

(DR. PETER SALGO)
Wet, wacky, and wobbly; this is why I love medicine.  Can you have NPH without all three of these symptoms? 

(DR. RALPH JÓSEFOWICZ)
Well of course, I mean things have to start someplace but the clue is when you develop all three symptoms within six months or so and that’s when you have to start thinking of this condition and that’s why the imaging study of the CAT scan or MR is important.

(DR. PETER SALGO)
Now, we’ve heard this is classic and everybody here perked up when they heard all three of these. How long did it take to get to this diagnosis for you two?

(ALAN DALE)
It took nearly three years, and it’s taken them ten minutes. Where was he?

(DR. RALPH JÓSEFOWICZ)
The thing is what I always teach my students is the number one rule of medicine is listen to your patients. She’s trying to tell you what’s wrong with her.

(DR. PETER SALGO)
Again, the 90% of the diagnosis you can tell by talking to somebody; not with the CT scan, not with the blood tests, with listening. It’s a lost art. If it took three years, what’s your guess why?

(DR. ALAN DENGIZ)
It’s hard for me to understand why it would take that long because I think all three of us within five minutes of hearing your story pretty much knew what you had. What I think is remarkable is that in spite of the fact that you had it for three years before it was diagnosed you seemed to have made a remarkable recovery.

(DR. LISA HARRIS)
I think the presumption was that she was eighty-three, there was a family history of Parkinson’s disease and they ran with that and all they heard was shuffling gait and didn’t listen any further to what the patient was saying.

(DR. RALPH JÓSEFOWICZ)
Premature closure.

(ALAN DALE)

Until the moment when the CAT scan was taken after the TIA, until that moment you know we had no real idea, never even heard of NPH. We were just so grateful that that stroke happened in fact.

(DR. PETER SALGO)
Well the near stroke anyway.  I want to just sort of sum up where we’ve been. Getting to the right diagnosis often involves working through a problem as the symptoms evolve. Some conditions such as normal pressure hydrocephalus can present with symptoms that can be misdiagnosed as other diseases, Parkinson’s for example and other conditions. Again, if your doctor isn’t listening to you, say it again, and if your doctor won’t listen to you, you need another doctor.

(DR. ALAN DENGIZ)
Another opinion, a second opinion. 

(DR. PETER SALGO)
Get a second opinion. Alright, let’s continue. We’re talking to Betty and Alan Dale, Betty you were diagnosed with normal pressure hydrocephalus or NPH. You’re in the hospital; you had a CT scan after having had a TIA. The doctors find enlarged ventricles, Alan, what did they say?

(ALAN DALE)
The doctors simply said that these ventricles didn’t look right and he would like to refer us to a neurosurgeon who would do a lumbar puncture.

(DR. PETER SALGO)
Ok, so right away you’ve gone from, ehh we don’t know to surgeon.  

(ALAN DALE)
Yes.

(DR. PETER SALGO)
What were you thinking? 

(ALAN DALE)
Relief, I think more than anything that somebody had finally found a possible cause for all Betty’s problems. 

(DR. PETER SALGO)
And did they mention NPH? 

(ALAN DALE)
Oh yes, the doctor did say perhaps NPH. 

(DR. PETER SALGO)
How common is NPH?

(DR. RALPH JÓSEFOWICZ)
It’s not very common but it certainly is something that should be considered in anyone with Betty’s story and that imaging finding on the CAT scan. 

(DR. PETER SALGO)
Are her symptoms reversible? 

(DR. RALPH JÓSEFOWICZ)
Yes, in this condition it is because the problem here is too much spinal fluid and it’s not draining properly and the way to treat the condition is to do a shunt, put a shunt in that basically drains the spinal fluid away from the ventricles and decreases the pressure.

(DR. PETER SALGO)
Anything else you need to do diagnostically? 

(DR. ALAN DENGIZ)
Well, they were going to do a spinal tap and in this situation I’m not even certain that was absolutely necessary because your case was so classic. What they will do is take spinal fluid out, a fairly large volume, and once they do that they will ask you to get up and to try and walk and generally your gait will improve after the fluid is removed. It will only be temporary at the point but it will let them know that a shunt may make the difference.

(DR. PETER SALGO)
Did they do that for you? Did they do one of those shunts rather than just withdraw large amounts of spinal fluid from the spinal tap. 

(BETTY DALE)
Yes. 

(ALAN DALE)
Yes, it was clear enough, Alan’s right. That said to them that Betty does have NPH, and let’s go ahead with the surgeon and put in the shunt.

(DR. PETER SALGO)
Well we’ve got some images of a shunt going in. Not yours, not your surgery. We can bring them up over here and what I want to show our viewers is what it looks like. You’re going to see it coming in on your left, that little white dot is the tip of the shunt catheter, they’re running it back and forth you see. You see it goes through the skull, it goes right in to that little darker area which are the ventricles.

(DR. RALPH JÓSEFOWICZ)
Right. 

(DR. PETER SALGO)
Now you don’t see the rest of it because of the way the scans are. It’s a tube that sits in the ventricle, comes out through the bone, and sits under the skin.

(DR. RALPH JÓSEFOWICZ)
It’s connected to a reservoir with two valves and they’re one way valves and they’re of a certain amount of pressure to allow the fluid to drain without causing problems.

(DR. PETER SALGO)
And there are two kinds of shunt valves; the fixed valves and the programmable valves because over time the pressure needs to change. You’re saying yes.

(ALAN DALE)
Yes. I do want to get my word in about that. Definitely the programmable one is the desirable one because things can change. If you have a fixed shunt and the right amount of fluid is not being drained off as evidenced by symptoms, you have to put in a new shunt, a new operation. With the programmable shunt it’s possible to program and change the amount of fluid through the shunt by means of a magnet which is just over the head.

(DR. PETER SALGO)
They just put a magnet over the… 

(ALAN DALE)
Yes, a device which will allow you to change the valve.

(DR. RALPH JÓSEFOWICZ)
And then the shunt is tunneled under the skin and typically in to the peritoneum, so in to the abdominal cavity and there it’s absorbed and that’s the end of the problem.

(DR. PETER SALGO)
How successful is a shunt? 

(DR. ALAN DENGIZ)
A shunt can be incredibly successful. The problem is that the earlier the diagnosis the better the recovery. If the diagnosis is made too late sometimes we don’t get full recovery of all three symptoms. Usually the gait would be the first thing to improve and then hopefully next the memory and then hopefully next the incontinence. 

(DR. LISA HARRIS)
And then she’ll also have to be monitored over time not just for issues with pressure but obstruction of the tip of the shunt and things like that. 

(DR. PETER SALGO)
At the end of the day, Betty, how did it make you feel and how long did it take, if you felt better, to feel better? 

(BETTY DALE)
Pretty much right away.

(DR. PETER SALGO)
Really?

(BETTY DALE)
Yes. 

(DR. PETER SALGO)
You’ve been watching and you live with her, is she back 100%? 

(ALAN DALE)
No, I don’t think 100%, after all there is three years of aging since she’s had it put in and you know, we can’t expect it to be 100% forever. Maybe what I’m seeing is what I should be seeing. I don’t think Betty’s memory is as good as it once was but I think it is quite good. And her walking is good, we don’t do long distance walks but I don’t think that’s really because of the gait issue. I think that’s just because the old legs are getting weaker.

(BETTY DALE)
And his legs aren’t too great. 

(DR. PETER SALGO)
You didn’t think you were going to get off scot-free, did you? 

(LAUGHING)

(ALAN DALE)
We don’t need to get in to that, do we? 

(DR. PETER SALGO)
How much of an improvement do folks expect? Do they get all the way back? 

(DR. ALAN DENGIZ)
If we diagnose it very, very promptly and accurately and a very good surgeon does it, yes, I’ve seen people come back fully. Majority of people do still have some residual …

(DR. LISA HARRIS)
And you remember three years of having brain tissue compressed so the fact that she’s made such an amazing recovery is amazing in itself.

(ALAN DALE)
Yes, I think that’s part of the problem. It took so long to figure it out. It’s so important, so many people are being misdiagnosed or not diagnosed at all and I think it’s very important that they get this right and get it right earlier so you have an earlier stage situation to correct. 

(DR. PETER SALGO)
Well I’m glad you did. I want to pause for a moment, sum up what we’ve been discussing again before we push forward. Normal pressure hydrocephalus, when diagnosed correctly, can be treated with surgery. Now the earlier the treatment, the more likely the symptoms are going to reverse and we get very good results. Now, right about this time on most of our broadcasts I would ask someone who’s had a problem ‘how are you doing?’ But I’ve got something better since you’ve shared something with us. I think that says it all.

(LAUGHING)

(DR. ALAN DENGIZ)
That’s called hydrodolphinus.

(DR. PETER SALGO)
And you know, with that, we’re out of time. Thank you both so much for being here. I think I can speak for all of us, we’re just thrilled they figured out what was wrong and that you’re doing so well. Thank you all for taking the challenge, I hope that you continue this conversation on our website. There you’re going to find the transcript of this show, more videos about normal pressure hydrocephalus, and links to resources. Now, the address is secondopinion/tv.org. Thanks for watching and to all of you for being here and being brave enough to do this in front of, we hope, millions of folks. Thank you for sharing everything with us.

(ALAN DALE)
Absolutely.

(DR. PETER SALGO)
I’m Dr. Peter Salgo and I’ll see you next time for another Second Opinion. 

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(ANNOUNCER)                   
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association, an association of independent, locally-operated and community-based Blue Cross and Blue Shield companies, supporting solutions that make safe, quality, affordable healthcare available to all Americans.

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Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, New York.