Caught in the “Web”: A Case Report of an Unusual Suspect for Shuffling Gait
Sanjana Palakodeti, Matthew Klumpp, Prashant NatteruABSTRACT
Background
Acqueductal web is a rare congenital anomaly that can cause obstruction of CSF flow from third ventricle to fourth ventricle.
Case Description
A 75‐year‐old man presented with a four‐month history of progressive gait disturbance with near‐falls and reported freezing episodes, urinary urgency with intermittent incontinence, and short‐term memory decline. Neurological examination showed mild bradykinesia, reduced right‐arm swing, and subtle parkinsonian features. Brain MRI revealed severe focal narrowing of the aqueduct of Sylvius at the level of the inferior colliculus with a small web‐like projection; phase‐contrast cine MRI demonstrated absent CSF flow across the stenotic segment, confirming near‐complete aqueductal obstruction. The patient underwent endoscopic third ventriculostomy with marked improvement in gait and cognition over four months.
Conclusion
This case illustrates that a presumed congenital aqueductal webs may remain clinically silent for decades and later present with the classic triad of gait disturbance, cognitive impairment, and urinary dysfunction, sometimes accompanied by parkinsonian signs; advanced CSF flow imaging is critical for diagnosis, and ETV can produce substantial clinical recovery in selected adults.