From the Guidelines
The primary treatment for Normal Pressure Hydrocephalus (NPH) is the surgical placement of a ventriculoperitoneal (VP) shunt, which diverts excess cerebrospinal fluid from the brain to the abdomen, where it can be absorbed 1.
Key Considerations
- The shunt is typically set to drain at a pressure of 100-150 mmH2O, and the valve is often programmable to allow for adjustments as needed.
- In some cases, a lumbar drain may be used as a temporary measure to assess the patient's response to CSF diversion, with drainage of 10-20 mL of CSF per day for 3-5 days.
- While medications such as acetazolamide (250-500 mg orally, twice daily) may be used to manage symptoms in patients who are not surgical candidates, this is not a primary treatment.
Treatment Approach
- The goal of treatment is to reduce symptoms and improve quality of life, with surgical intervention being the most effective approach for eligible patients.
- The use of cerebrospinal fluid diversion is a key component of NPH treatment, as seen in the management of other forms of hydrocephalus 1.
From the Research
Treatment Options for Normal Pressure Hydrocephalus (NPH)
The treatment for Normal Pressure Hydrocephalus (NPH) typically involves cerebrospinal fluid (CSF) diversion procedures. The following are some of the treatment options:
- Ventriculoperitoneal (VP) Shunt: This is the most common treatment for NPH, where a shunt is placed to divert CSF from the brain to the abdomen 2, 3, 4, 5, 6.
- Lumboperitoneal (LP) Shunt: This is an alternative treatment option that involves placing a shunt to divert CSF from the lumbar cistern to the abdomen 3, 5.
- Ventriculoatrial (VA) Shunt: This treatment option involves placing a shunt to divert CSF from the brain to the heart 4, 5.
- Endoscopic Third Ventriculostomy (ETV): This is a minimally invasive procedure that involves creating a hole in the third ventricle to allow CSF to flow out of the brain 5, 6.
Efficacy of Treatment Options
The efficacy of these treatment options varies, with some studies showing significant improvement in symptoms, while others show limited or no improvement. According to a systematic review and meta-analysis, the overall efficacy of CSF diversion procedures for NPH is around 74%, with VP shunting demonstrating an efficacy of 75%, VA shunting at 75%, and LP shunting at 70% 5.
Complications and Risks
All treatment options carry some risk of complications, including infection, bleeding, and shunt malfunction. According to a systematic review and meta-analysis, the complication rate for VP shunting is around 20.6%, with a surgery revision rate of 15.1% 5. ETV, on the other hand, has been shown to have a significantly lower complication rate compared to VP shunting, with a complication rate of 7.5% 6.
Patient Selection and Outcome
The outcome of treatment for NPH depends on various factors, including patient selection, shunt type, and surgical technique. According to a study, standardized assessment of gait, balance, and cognition before and after temporary CSF diversion can help identify patients who are likely to benefit from VP shunting 2. Another study found that ETV and VP shunting did not differ significantly in terms of failure rate or postoperative improvement, but ETV had a significantly lower complication rate 6.