From the Research
The primary treatment for Normal Pressure Hydrocephalus (NPH) is surgical placement of a ventriculoperitoneal (VP) shunt or a lumboperitoneal (LP) shunt, with the most recent and highest quality study suggesting that LP shunts may be a safe and effective alternative to VP shunting 1. This procedure involves inserting a thin tube (catheter) into the brain ventricles or lumbar space to drain excess cerebrospinal fluid (CSF) into the peritoneal cavity where it can be absorbed by the body. Before committing to surgery, patients typically undergo a diagnostic lumbar tap test where 30-50 mL of CSF is removed to temporarily relieve symptoms and predict shunt responsiveness. The success rate of shunt surgery varies, with approximately 60-80% of properly selected patients showing improvement, as reported in a study of 116 patients with NPH who underwent VP shunt placement 2. Best results occur when treatment is initiated early, particularly within months of symptom onset. Patients with the classic triad of gait disturbance, urinary incontinence, and cognitive decline tend to respond better to shunting. Post-surgery, patients require regular follow-up to monitor shunt function and may need shunt adjustments. Some key considerations for shunt placement include:
- Setting the valve opening pressure close to the lumbar puncture opening pressure to decrease overdrainage, as suggested by a study published in 2020 3
- Using programmable shunts to noninvasively manage overdrainage complications
- Considering LP shunts as an alternative to VP shunting, particularly for patients where cranial approaches should be avoided, as reported in a study published in 2021 1 Complications can include infection, bleeding, shunt malfunction, or overdrainage, occurring in about 30% of cases. While medication alone cannot treat NPH effectively, managing contributing conditions like hypertension or diabetes is important. Physical therapy is often recommended as an adjunct treatment to improve gait and balance following shunt placement. It is also important to note that recent studies have led to improved recognition of overlapping diseases such as Alzheimer pathology, which co-occurs in about 30% of NPH cases, and the use of imaging modalities like fludeoxyglucose positron emission tomography (FDG-PET) to diagnose NPH and detect concomitant degenerative disease 4.