From the Guidelines
Normal pressure hydrocephalus (NPH) is characterized by a classic triad of symptoms: gait disturbance, urinary incontinence, and cognitive decline, which can be potentially treated with surgical placement of a shunt to improve symptoms. The symptoms of NPH overlap with those of other conditions, but typically include:
- Gait problems, such as a slow, shuffling, wide-based "magnetic" gait
- Urinary symptoms, including urgency, frequency, and eventual incontinence
- Cognitive changes, such as slowed thinking, apathy, forgetfulness, and difficulty with complex tasks Additional symptoms may include headaches, lethargy, and balance problems 1. It is essential to recognize NPH, as it can be treated with surgical intervention, which may improve symptoms, especially if diagnosed early 1. The diagnosis of hydrocephalus can be confirmed with imaging studies, such as a contrast-enhanced MRI, which can evaluate for the presence of ventriculomegaly and transependymal edema, hallmarks of acute hydrocephalus 1. Lumbar puncture may also be suggestive of the diagnosis of hydrocephalus by virtue of the increased opening pressure, although ventricular fluid pressure may be normal in some cases, and this finding alone should not be used to exclude the diagnosis of meningitis 1. In cases where medical therapy fails to stabilize the pressure, lumboperitoneal or other shunting procedures may need to be explored with neurosurgery 1.
From the Research
Normal Pressure Hydrocephalus Symptoms
The symptoms of Normal Pressure Hydrocephalus (NPH) can be characterized by a classic triad, including:
- Gait disturbance
- Urinary incontinence
- Dementia 2, 3, 4, 5, 6 These symptoms are often associated with radiological verifiable ventriculomegaly in the absence of elevated cerebrospinal fluid (CSF) pressure 2.
Diagnosis and Treatment
Diagnosing NPH can be challenging, as many patients do not present with classical clinical and radiological findings 2. However, various supplemental preoperative tests, including lumbar CSF tap test or CSF outflow resistance determination, can improve the accuracy of predicting a response to surgical intervention 2. CSF shunt surgery is a common treatment option for NPH, which can result in significant reduction of symptoms in the majority of appropriately evaluated patients 2, 5.
Importance of Early Diagnosis
Early diagnosis of NPH is crucial, as it can increase the rate of success to treatment 3. Accurate diagnosis and identification of responders to treatment are important, and a screening tool can be used to identify possible cases, followed by further workup to confirm the diagnosis and determine the need for shunting 3.
Reversibility of Symptoms
NPH is one of the few reversible causes of dementia, and early therapy can lead to a complete reversal of symptoms 4. The gait symptoms respond the most to surgery, and improved shunting modalities and novel shunt materials with valve adjustments have improved the precision of the shunting procedures 5.