To describe a case of NPH presenting with only severe intermittent calf claudication.

Claudication consists of muscle cramping and pain with prolonged walking typically secondary to lumbar stenosis or arterial occlusive disease. NPH has a well-established pattern of symptomology including gait dysfunction, urinary incontinence, and cognitive changes. Calf claudication has never been reported as a symptom of NPH.

A 67-year-old previously active man presented with progressively worsening claudication for 1 year. He described new-onset low back pain, weakness, fatigue, and tingling in his calves after walking 50 feet. Symptoms were relieved by stopping, sitting, or leaning forward. 

Three years later, he developed severe cramping and imbalance after taking a few steps and required a wheelchair. Neurologic exam was normal outside of gait instability without evidence of magnetism, en-bloc turning, gait hesitation, or leg weakness.

He denied any urinary or cognitive issues.

N/A

Vascular studies, EMG, and MRI lumbar-spine were fairly unremarkable and unrevealing for a clear etiology.

MRI brain was consistent with disproportionally enlarged subarachnoid space hydrocephalus in idiopathic NPH. He underwent a timed walk test pre- and post- large-volume lumbar puncture (LP). Pre-procedurally, he walked 15 feet over 1 minute with a walker before unbearable calf cramping. Post-procedurally, he walked 95 feet over 1 minute without assistance, back pain, leg cramping, or weakness. A ventriculoperitoneal shunt was placed and he walked 190 feet over 1 minute, pain-free with a cane.

NPH has a well-recognized triad of gait disorder, urinary incontinence, and cognitive decline. However, our patient’s clinical picture was dominated by calf claudication and imbalance without any urinary or cognitive issues. Claudication has never been described in association with NPH. Given the unremarkable vascular studies and lumbar MRI, plus the significant improvement of claudication with large-volume LP, it suggests that claudication may be an atypical presenting symptom of NPH.