What is the treatment for Normal Pressure Hydrocephalus (NPH)?

Treatment of Normal Pressure Hydrocephalus

Ventriculoperitoneal (VP) shunt placement is the definitive treatment for Normal Pressure Hydrocephalus, resulting in clinical improvement in 70-90% of patients and representing the only effective intervention to prevent progression to nursing care dependence. 1, 2

Patient Selection and Pre-Surgical Evaluation

Before proceeding with surgical intervention, confirm the diagnosis and predict shunt responsiveness:

• Obtain MRI with contrast to evaluate ventriculomegaly and exclude alternative diagnoses such as cerebral atrophy or other neurodegenerative conditions 1
• Perform lumbar puncture or extended lumbar drainage as a predictive test—patients demonstrating clinical improvement with temporary CSF removal are highly likely to benefit from permanent shunting 3, 4
• Use standardized assessments including Timed "Up & Go", Tinetti Gait and Balance Assessment, Berg Balance Scale, and cognitive testing (Mini Mental Status Exam, Trail Making Test Part B) before and after lumbar drain placement 4
• Patients showing improvement in Tinetti scores (mean increase of 4.27 points) after lumbar drain are strong candidates for VP shunt 4

Surgical Treatment Options

Primary Recommendation: Ventriculoperitoneal Shunt

VP shunt with programmable valves is the standard of care, providing sustained symptom improvement with acceptable complication rates 1, 5, 2:

• Gait disturbance shows the best and most sustained improvement (100% improvement rate in some series) 3, 5
• Urinary incontinence improves in 46-55% of patients 3, 5
• Cognitive impairment improves in 55% of patients, though may decline in long-term follow-up 3, 5
• Use stereotactic navigation for proximal catheter placement and laparoscopic assistance for distal catheter placement to minimize complications—this technique results in zero reoperations within 30 days and only 3.4% requiring revision 6

Alternative Option: Lumboperitoneal Shunt

Lumboperitoneal (LP) shunts with horizontal-vertical valves are a safe alternative that avoids direct cerebral injury and may reduce overdrainage risk 3:

• Results in 100% gait improvement, 46% incontinence improvement, and 55% memory improvement 3
• Lower risk of subdural hemorrhage compared to VP shunts (0% vs. up to 10% with VP shunts) 3
• Consider LP shunts specifically for patients who demonstrate improvement following lumbar drainage 3
• Shunt failure requiring revision occurs in 27% at mean 11 months 3

Endoscopic Third Ventriculostomy (ETV)

ETV is an alternative to VP shunts in selected patients, though evidence for NPH specifically is limited 1:

• When adjusted for age and etiology, ETV has higher early failure rates than shunts but lower failure rates after 3 months 1
• Overall outcomes are equivalent to CSF shunts in many clinical scenarios 1
• Consider ETV in younger patients or those with specific anatomical considerations 1

What NOT to Do

Avoid these ineffective or harmful interventions:

• Do NOT use serial lumbar punctures as definitive treatment (Level I evidence against routine use) 1
• Do NOT prescribe acetazolamide or furosemide—these medications do not reduce shunt placement needs and may increase morbidity 7, 8
• Do NOT use intraventricular thrombolytics (tPA, urokinase, streptokinase) as they provide no benefit 8

Post-Operative Management and Follow-Up

Strict long-term follow-up is essential for optimal outcomes 5:

• Approximately 89.6% of patients report symptomatic improvement at 6 weeks post-shunt 4
• However, 45.5% report symptom recurrence at 1 year, requiring valve adjustment or revision 4
• Shunt malfunction requiring revision occurs in 20-27% of patients 3, 5
• Valve pressure adjustments are needed in 40% of patients and result in clinical improvement in 93.3% of cases 5
• Monitor for subdural fluid collections (occurs in 18% on postoperative imaging) 4

Common Pitfalls and Complications

Be aware of these critical issues:

• Subdural hemorrhage/fluid collection is the most common serious complication (6-18% incidence) 4, 6
• Infection occurs in approximately 6% of cases 3
• Systemic complications total 12% in the first 30 days 6
• Three-quarters of NPH patients have coexisting neurodegenerative disorders, complicating diagnosis and potentially limiting treatment response 2
• Approximately 80% of NPH cases remain unrecognized and untreated, leading to nursing care dependence 2
• Patients with cardiac or other neurological comorbidities have higher readmission and complication rates 6

Long-Term Outcomes

Surgical treatment provides sustained benefit for most patients 5:

• Significant and lasting improvement in all symptoms compared to baseline over 10+ years of follow-up 5
• Gait shows the best sustained improvement 5
• Cognitive impairment and urinary incontinence improve early but may decline in long-term follow-up 5
• Without treatment, the spontaneous course ends in nursing care dependence for the vast majority of patients 2