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Normal pressure hydrocephalus

Last edited: 4/14/2026

Overview

Normal pressure hydrocephalus (NPH) is a neurological disorder characterized by gait disturbance, cognitive impairment, and urinary incontinence in elderly patients, often mimicking other neurodegenerative conditions like Alzheimer's disease 13.

Diagnosis

  • Clinical Criteria: Presence of classic triad: gait disturbance, cognitive impairment, and urinary incontinence 3.
  • Imaging: MRI showing enlarged ventricles with normal or near-normal cerebrospinal fluid (CSF) pressure 3.
  • Lumbar Puncture: CSF analysis may show normal pressure, though sometimes mild abnormalities can be present 3.
  • Neuropsychological Testing: To assess cognitive function and differentiate from Alzheimer's disease 1.
  • Cortical Pathology Assessment: Consideration of Alzheimer's disease-related cortical pathology via immuno-analysis to refine diagnosis 1.

    • Management

  • First-Line Treatment: CSF shunting surgery to reduce ventricular size and alleviate symptoms 3.
  • Adjunctive Therapies: Cognitive rehabilitation and physical therapy to support functional improvement 3.
  • Monitoring: Regular follow-up to assess clinical outcomes and shunt function 3.

    • Special Populations

  • Elderly: NPH predominantly affects the elderly population, with diagnostic and management approaches tailored to this age group 3.
  • Comorbidities: Consideration of coexisting conditions like Alzheimer's disease, which may influence treatment response and outcomes 1.

    • Key Recommendations

  • Perform CSF shunting for patients meeting clinical criteria of NPH to improve gait, cognition, and urinary control (Evidence: Strong 3).
  • Incorporate neuropsychological testing to differentiate NPH from Alzheimer's disease and guide management decisions (Evidence: Moderate 1).
  • Consider cortical pathology analysis in patients with uncertain diagnosis to better predict shunting outcomes (Evidence: Moderate 1).
  • Regular clinical follow-up post-shunting is essential to monitor efficacy and manage complications (Evidence: Expert opinion 3).

    • References

    1 Greenberg ABW, Mekbib KY, Mehta NH, Kiziltug E, Duy PQ, Smith HR et al.. Utility of cortical tissue analysis in normal pressure hydrocephalus. Cerebral cortex (New York, N.Y. : 1991) 2024. link 2 Stoddart C. Air-Assisted Technology: A Quality Endeavor to Reduce Employee Injury and Hospital-Acquired Pressure Injuries. Critical care nursing quarterly 2022. link 3 Nakajima M, Yamada S, Miyajima M, Ishii K, Kuriyama N, Kazui H et al.. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurologia medico-chirurgica 2021. link 4 Baek SJ, Chen LZM, Shah PR, Fitzsimons R. Comparison of Subjective and Objective Torsion in Normal Patients. Journal of pediatric ophthalmology and strabismus 2021. link 5 Sward LB, Tariq SG. Maternal-Fetal Physiology, Intrapartum Care, Postpartum Care: A Team-Based Learning Module for Normal Obstetrics. MedEdPORTAL : the journal of teaching and learning resources 2019. link 6 Oberfoell S, Murphy D, French A, Trent S, Richards D. Inter-rater Reliability of Sonographic Optic Nerve Sheath Diameter Measurements by Emergency Medicine Physicians. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine 2017. link 7 Forkert ND, Li MD, Lober RM, Yeom KW. Gray Matter Growth Is Accompanied by Increasing Blood Flow and Decreasing Apparent Diffusion Coefficient during Childhood. AJNR. American journal of neuroradiology 2016. link 8 Hutton EK, Stoll K, Taha N. An observational study of umbilical cord clamping practices of maternity care providers in a tertiary care center. Birth (Berkeley, Calif.) 2013. link 9 Walker D, DeMaria LM, Suarez L, Cragin L. Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines?. Journal of midwifery & women's health 2012. link 10 Wyatt HJ. The human pupil and the use of video-based eyetrackers. Vision research 2010. link 11 Zagers NP, van de Kraats J, Berendschot TT, van Norren D. Simultaneous measurement of foveal spectral reflectance and cone-photoreceptor directionality. Applied optics 2002. link 12 . Care in normal birth: a practical guide. Technical Working Group, World Health Organization. Birth (Berkeley, Calif.) 1997. link 13 Galassi F, Sodi A, Rossi MG, Ucci F, De Saint Pierre F. Ocular haemodynamics in some subgroups of normal pressure glaucoma. Acta ophthalmologica Scandinavica. Supplement 1997. link 14 Kanpolat A, Simşek T, Alp NM. The evaluation of normal corneal topography in emmetropic eyes with computer-assisted videokeratography. The CLAO journal : official publication of the Contact Lens Association of Ophthalmologists, Inc 1997. link 15 Khan AH, Saha DK, Biswas SK. Urine level of trace elements in some adults in Bangladesh under a workplace environment. International journal of radiation applications and instrumentation. Part A, Applied radiation and isotopes 1990. link90099-3) 16 Miodrag A, Das TK, Shepherd RJ. Normal pressure hydrocephalus presenting as Parkinson's syndrome. Postgraduate medical journal 1987. link 17 Kwentus JA, Hart RP. Normal pressure hydrocephalus presenting as mania. The Journal of nervous and mental disease 1987. link 18 Auer RN, Gilbert JJ. Cavum vergae without cavum septi pellucidi. Archives of pathology & laboratory medicine 1982. link 19 Kollarits CR, Kollarits FJ, Schuette WH, Whitehouse WC, Gunkel RD. The pupil dark response in normal volunteers. Current eye research 1982. link

    Original source

    1. [1]
      Utility of cortical tissue analysis in normal pressure hydrocephalus. — Greenberg ABW, Mekbib KY, Mehta NH, Kiziltug E, Duy PQ, Smith HR et al. Cerebral cortex (New York, N.Y. : 1991) (2024)
    2. [2]
      Air-Assisted Technology: A Quality Endeavor to Reduce Employee Injury and Hospital-Acquired Pressure Injuries. — Stoddart C Critical care nursing quarterly (2022)
    3. [3]
      Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. — Nakajima M, Yamada S, Miyajima M, Ishii K, Kuriyama N, Kazui H et al. Neurologia medico-chirurgica (2021)
    4. [4]
      Comparison of Subjective and Objective Torsion in Normal Patients. — Baek SJ, Chen LZM, Shah PR, Fitzsimons R Journal of pediatric ophthalmology and strabismus (2021)
    5. [5]
      Maternal-Fetal Physiology, Intrapartum Care, Postpartum Care: A Team-Based Learning Module for Normal Obstetrics. — Sward LB, Tariq SG MedEdPORTAL : the journal of teaching and learning resources (2019)
    6. [6]
      Inter-rater Reliability of Sonographic Optic Nerve Sheath Diameter Measurements by Emergency Medicine Physicians. — Oberfoell S, Murphy D, French A, Trent S, Richards D Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine (2017)
    7. [7]
      Gray Matter Growth Is Accompanied by Increasing Blood Flow and Decreasing Apparent Diffusion Coefficient during Childhood. — Forkert ND, Li MD, Lober RM, Yeom KW AJNR. American journal of neuroradiology (2016)
    8. [8]
      An observational study of umbilical cord clamping practices of maternity care providers in a tertiary care center. — Hutton EK, Stoll K, Taha N Birth (Berkeley, Calif.) (2013)
    9. [9]
      Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines? — Walker D, DeMaria LM, Suarez L, Cragin L Journal of midwifery & women's health (2012)
    10. [10]
      The human pupil and the use of video-based eyetrackers. — Wyatt HJ Vision research (2010)
    11. [11]
      Simultaneous measurement of foveal spectral reflectance and cone-photoreceptor directionality. — Zagers NP, van de Kraats J, Berendschot TT, van Norren D Applied optics (2002)
    12. [12]
      Care in normal birth: a practical guide. Technical Working Group, World Health Organization. Birth (Berkeley, Calif.) (1997)
    13. [13]
      Ocular haemodynamics in some subgroups of normal pressure glaucoma. — Galassi F, Sodi A, Rossi MG, Ucci F, De Saint Pierre F Acta ophthalmologica Scandinavica. Supplement (1997)
    14. [14]
      The evaluation of normal corneal topography in emmetropic eyes with computer-assisted videokeratography. — Kanpolat A, Simşek T, Alp NM The CLAO journal : official publication of the Contact Lens Association of Ophthalmologists, Inc (1997)
    15. [15]
      Urine level of trace elements in some adults in Bangladesh under a workplace environment. — Khan AH, Saha DK, Biswas SK International journal of radiation applications and instrumentation. Part A, Applied radiation and isotopes (1990)
    16. [16]
      Normal pressure hydrocephalus presenting as Parkinson's syndrome. — Miodrag A, Das TK, Shepherd RJ Postgraduate medical journal (1987)
    17. [17]
      Normal pressure hydrocephalus presenting as mania. — Kwentus JA, Hart RP The Journal of nervous and mental disease (1987)
    18. [18]
      Cavum vergae without cavum septi pellucidi. — Auer RN, Gilbert JJ Archives of pathology & laboratory medicine (1982)
    19. [19]
      The pupil dark response in normal volunteers. — Kollarits CR, Kollarits FJ, Schuette WH, Whitehouse WC, Gunkel RD Current eye research (1982)
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