Absolute Treatment for Normal Pressure Hydrocephalus (NPH)
Ventriculoperitoneal (VP) shunt placement is the definitive treatment for NPH, providing sustained clinical improvement for 5-7 years in appropriately selected patients. 1
Primary Treatment: VP Shunt
VP shunt remains the gold standard and most common treatment for NPH according to the American Academy of Neurology. 2 This procedure achieves:
- Clinical improvement in 89.6% of patients at 6-week follow-up 3
- Sustained benefit for 5-7 years in properly selected candidates 1
- Most significant improvement in gait disturbance, followed by lesser improvements in cognition and incontinence 4
Patient Selection Criteria
Before proceeding with VP shunt, patients must demonstrate objective improvement after temporary CSF diversion testing:
- Lumbar drain trial is mandatory to predict shunt responsiveness 4, 3
- Shorter duration of gait disturbance predicts better outcomes (p<0.01) 4
- Validated testing should include: Timed "Up & Go", Tinetti Gait and Balance Assessment, Berg Balance Scale, Mini Mental Status Exam, Trail Making Test Part B 3
- Mean Tinetti score improvement of 4.27 points after lumbar drain distinguishes shunt responders from non-responders (p<0.001) 3
Alternative Treatment: Endoscopic Third Ventriculostomy (ETV)
ETV has emerged as an alternative with distinct advantages and limitations:
- Lower long-term complication rates compared to VP shunts 2, 1, 5
- Higher early failure rates than shunts but lower failure rates after 3 months 2, 1, 5
- Equivalent overall outcomes to VP shunts when adjusted for patient age and etiology 2, 5
- Preferred when suitable anatomy exists, particularly in aqueductal stenosis 1
The Congress of Neurological Surgeons provides Level II evidence that both CSF shunts and ETV are acceptable options, though VP shunt remains more commonly utilized. 5
Critical Complications to Monitor
Short-Term Complications (within 6 months):
- Subdural fluid collections occur in 18% of patients 3
- Misplaced proximal catheters, asymptomatic hemorrhages, and CSF leaks 4
- Overall complication rate approximately 6% including seizure, intracerebral hemorrhage, and stroke 3
Long-Term Complications:
- Infection risk of 11% within 24 months requiring complete shunt removal with systemic antibiotics 1
- Symptom recurrence in 45% of patients at 1-year follow-up despite initial improvement 1, 3
- Shunt occlusion occurs in 7% of patients during follow-up 6
What NOT to Do
Serial lumbar punctures are NOT recommended as definitive treatment (Level I evidence, high clinical certainty). 7, 5 They do not reduce the need for shunt placement or prevent hydrocephalus progression. 7
Optimal Valve Settings
For programmable valves in VP shunts:
- Median opening pressure: 120 mmH₂O for women, 140 mmH₂O for men 8
- Valve settings should prioritize clinical condition over radiological findings, as these parameters are independent of each other 8
Prognostic Factors
Positive predictors of shunt success:
- Shorter duration of symptoms before treatment 4
- Use of cognition-enhancing medications predicts improvement in cognition and incontinence (p<0.05) 4
Negative predictors:
- Diabetes mellitus and history of stroke correlate with worse surgical outcomes (p<0.05) 8