Clin Geriatr Med 22 (2006) 645–657

Normal Pressure Hydrocephalus: Diagnosis and New Approaches to Treatment
Ronan Factora, MDa,*, Mark Luciano, MD, PhDb
Section of Geriatric Medicine, Department of General Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA b Department of Neurosurgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
a

Impairment of gait occurs commonly in the elderly and has a profound impact on individual functional capacity and quality of life. Dementia and urinary incontinence are other common problems encountered in the elderly. In many circumstances, these problems are mutually exclusive, with treatments chosen to address each disease entity separately. When they appear over time in the same patient, however, these symptoms raise the possibility of normal pressure hydrocephalus (NPH). NPH first was described in 1965 in a series of papers by the Columbian neurosurgeon, Dr. Solomon Hakim. Subsequently, estimates of the prevalence of NPH have varied and the role of ventricular shunting debated. The diagnosis of NPH in elderly patients is suspected on the basis of enlarged cerebral ventricles with one or more of the Adam’s triad of symptoms: gait imbalance, dementia, and urinary incontinence [1]. The incidence of NPH remains uncertain, as diagnostic features and prevalence rates vary widely across reporting centers. Rates vary from 1.3 per million to 4 per 1000, depending on diagnostic criteria for NPH and populations sampled. Recent estimates quote an annual incidence of 1.8 per 100,000 inhabitants using a survey of 49 centers in Europe [2]. NPH usually occurs in the sixth to seventh decades of life [1,3]. Because treatment for NPH differs from that for other gait disorders and success of treatment may be dramatic, it is worthwhile to identify appropriate patients for cerebrospinal shunting. The challenge in the elderly
* Corresponding author. Cleveland Clinic Foundation, Section of Geriatric Medicine, Department of General Internal Medicine, Desk A91, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address: factorr@ccf.org (R. Factora). 0749-0690/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cger.2006.05.001 geriatric.theclinics.com

The diagnosis and treatment of NPH is facilitated by communication and collaboration between geriatricians and neurosurgeons. impaired smooth pursuit. which is attributed to lateral ventricle compression of the fibers of the corticospinal tracts that supply the legs along the corona radiata [9. this coordination takes the form of an interdisciplinary clinic. although the existence of these gradients are not well established. Pathophysiology The exact mechanism of the ventriculomegaly in NPH remains unclear. leading to subsequent urinary urgency and incontinence [9]. Diagnosis and diagnostic challenges Identification of symptoms in Adam’s triad is simple. which attempts to differentiate multiple causes of cognitive impairment and gait decline. to optimize medical management of these causes. but determining which patients truly have NPH and will benefit from shunting not always is straightforward. and impaired suppression of vestibuloocular reflexes. and optimize NPH patients’ course post shunting. attributed to motor deficits. The gait apraxia is multifactorial in nature. Another theory states that increases in subependymal CSF accumulation along with stretching of the periventricular white matter leads to changes in subcortical white matter. Development of a transmantle gradient (between the ventricles and the cortical subarachnoid space) resulting from outflow obstruction at the basilar cisterns also are believed to lead to continuous ventriculomegaly or enlargement [7]. evaluate. One proposes that in adult hydrocephalus. ventriculomegaly results from diminished elasticity of brain [6].10].11]. but various hypotheses exist. Although patients need not have all three symptoms for NPH to be considered. Difficulty in turning occurs because patients feel unsteady . At the authors’ institution. subsequently. The ‘‘magnetic gait’’ refers to the characteristic wide-based stance. short small steps. Similarly. the gait deficit is considered the most crucial for diagnosis. compression of sacral fibers along the corona radiata may be responsible for impairment of inhibitory fibers supplying the bladder.5]. and to follow. and reduced floor clearance in patients who have NPH [9. to screen for patients who potentially may benefit from cerebrospinal fluid (CSF) shunting. ventriculomegaly develops as a result of a combination of a slightly elevated baseline CSF pressure and intermittent increased CSF pressure waves [4. impaired postural righting reflexes.646 FACTORA & LUCIANO population is sorting through changes that result from normal aging and those comorbid illnesses commonly encountered when making this determination. Development of ventriculomegaly likely produces clinical symptoms through compression of adjacent brain tissues and decreased cerebral blood flow [8]. Gait impairment typically is the first symptom noted.

the probability that all of Adam’s triad is present increases. In this case. Unlike Parkinson’s disease. The shuffling aspect of this gait deficit has some similarities to and often is confused with Parkinson’s disease.NORMAL PRESSURE HYDROCEPHALUS 647 and make the transition in very small broad-based. arrhythmias. The possibility of the coexistence of multiple causes for gait impairment is higher in the elderly population. For example. As time passes. In one study. Observed shuffling gait along with tremor or bradykinesia may lead to an incorrect diagnosis of parkinsonism. such as gaze palsy or autonomic dysfunction (dysphagia. Timing in the onset of these symptoms can be helpful in determining whether or not the presence of these symptoms truly represents NPH or is explained by other diagnoses. all characteristic of parkinsonism. Consequently. presence of the complete Adam’s triad in patients who had a clinical suspicion of NPH had a positive predictive value of 64% and negative predictive value of 82% [12]. It also may limit rehabilitative potential if shunt placement proceeds. Reflex findings are variable and not consistently diagnostic. and sensory examination usually is intact. as a result of dementia or reduced ability to get to the bathroom in time. it may be reasonable to pursue . rigidity. If patients have cognitive deficits without gait involvement. MRI of the lumbosacral spine aids in diagnosis. multiple steps. urinary frequency with urgency is noted first. Differential diagnosis Evaluation of gait should take into consideration potential causes aside from NPH. before the development of incontinence. Lumbar canal stenosis can interfere with a trial of CSF drainage used for predictive purposes in NPH. patients who have features of NPH also can have significant lumbar canal stenosis impeding gait. Typically. gait impairment is the first symptom. help differentiate it from NPH. however. Appearance of the gait may resemble shuffling: resting ‘‘pill-rolling’’ tremor of the hands. with cognitive symptoms (eg. the diagnosis of NPH is highly unlikely. orthostatic hypotension. As the development of symptoms in NPH is a continuum. History significant for back pain or lower extremity weakness and radicular pain can lead to a diagnosis of lumbar canal stenosis. Typically. bradykinesia. Parkinson-like features may be present in late NPH and typically do not respond to levodopa. patients who have NPH do not have tremor. and freezing. executive dysfunction) occurring later. Features of Parkinson-plus syndromes. A steppage gait suggests the presence of peripheral neuropathy and is distinguishable from the wide base and diminished step gait associated with NPH. or urinary retention). not all of the symptoms may be severe enough to be noticed initially. identification of these etiologies should be coupled with the determination of which cause is the greater contributing factor to gait impairment. in the presence of a shuffling gait reduce the clinical suspicion of NPH.

differentiate it from Alzheimer’s disease. identifying specific cognitive deficits can be helpful in correct diagnosis. forgetfulness (without complete memory loss). and executive dysfunction. The presenting symptoms of cognitive impairment can be similar in NPH and other dementias in elderly patients. depression. and frank memory loss. leading to slowness of movement and function. agnosia. and may have focal neurologic deficits on examination. apraxia. There is greater difficulty separating the features of cognitive impairment associated with NPH from other comorbidities associated with subcortical deficits (vascular dementia. visuospatial dysfunction. and frontal lobe dementias). Alzheimer’s disease typically presents insidiously over years. Using the brief Mini–Mental State Examination (MMSE) aids in diagnosing dementia. including anomia. apraxia. . with progressive memory impairment and development of additional features. Dementia in NPH typically has subcortical features. Vascular dementia classically presents as a stepwise decline over time. Table 1 helps illustrate the differences between cognitive impairment encountered in NPH and the classical presentations of Alzheimer’s disease and vascular dementia. and impaired executive function. Patients who have vascular dementia also may have emotional lability. Historical clues and physical examination findings are the most useful factors in distinguishing between them. such anomia. although MMSE has its limitations in assessing severity of subcortical deficits (which may be identified more Table 1 Comparison of dementia characteristics Alzheimer’s disease Memory impairment Executive dysfunction Impaired visuospatial process Impaired language Impaired complex motor skills Psychomotor slowing Impaired attentiveness a Vascular dementia X X Xa Normal pressure hydrocephalus Impaired retrieval X X X X X X Xa Xa Bradyphrenia X X Can occur based on location of infarction. Absence of cortical features.648 FACTORA & LUCIANO treatment of lumbar canal stenosis rather than moving directly to shunt placement. with more prominent loss of higher-order cognitive functions. When evaluating dementia. including executive function and visuospatial perception. may develop sundowning.

urinary incontinence is common. Ventricular enlargement with gyral effacement against the skull is more suggestive of acute hydrocephalus. Identifiable causes may include bladder outlet obstruction resulting from benign prostatic hypertrophy. Increases in fluid spaces in the hemispheric sulci and subarachnoid spaces proportional to ventricular expansion may be more likely to be present in ex vacuo hydrocephalus. Because some degree of atrophy is ubiquitous in this age group and may even be exacerbated by known vascular disease. In the elderly population. Cognitive deficits are similar to those found in subcortical dementias. Presence of temporal lobe or hippocampal atrophy also may support a diagnosis of Alzheimer’s disease. Depression also can present with memory loss or executive dysfunction and can be mistaken for dementia. Diagnostic evaluation Neuroimaging in the form of CT or MRI is needed to confirm the presence of enlarged ventricles. movement of the CSF can be monitored to identify blockages. Identifying the specific type of incontinence (eg. The 15-question Geriatric Depression Scale may be able to identify depressed individuals to initiate proper therapy. retention resulting from neurogenic bladder (from longstanding diabetes or related to Parkinson’s disease). which is useful because it can be performed easily on available CT or MRI scans. especially regarding the presence of cerebrovascular disease. Although ventricular enlargement may seem straightforward. MRI may be more useful than CT in identifying other CNS disorders and providing greater detail. By gating the MRI to the cardiac cycle and CSF oscillatory flow (MRI cine CSF flow).NORMAL PRESSURE HYDROCEPHALUS 649 easily using the Clock Drawing Test or Trail-Making Test). a common problem is distinguishing true hydrocephalus (a problem in CSF circulation) from ventriculomegaly ex vacuo (a parenchymal disease). It also can be useful in measuring response to interventions or progression over time. Measurement of the Evans ratio is a crude unidimensional measurement of ventricular width. and surgical intervention is considered. urge. and pelvic floor insufficiency contributing to stress incontinence. This value is defined as the ratio of the maximum width of the anterior ventricular horns at the level of the foramen . especially in the aqueduct between the thirdrd and fourth ventricles. Hyperdynamic flow demonstrated in the aqueduct supports a diagnosis of NPH. More advanced neuropsychiatric testing can be useful to aid in appropriate diagnosis when evaluating patients whose pattern of cognitive deficits is unclear. or functional) is useful in determining the underlying cause. stress. the criteria of pathologic enlargement in the aging population is not established. Judicious use of cystoscopy and urodynamic testing can help in evaluation of patients whose diagnosis is unclear. Detection of obstruction as a cause of chronic hydrocephalus obviates CSF drainage tests. overflow.

4 [13]. Newer technologies (positron emission tomography. 1. Many neurosurgeons Fig. single photon emission CT. A ratio greater than or equal to 0. Although Evan’s ratio is a handy rule of thumb for identifying the existence of ventricular enlargement. . and functional MRI) provide information regarding blood flow. therefore. such as parkinsonism. oxygen delivery. but most patients who have NPH have a ratio greater than or equal to 0. patients who have NPH present with the symptoms of Adam’s triad. Without validated and definitive clinical criteria for the diagnosis of treatable cases of NPH. Patients are divided into four quadrants based on a combination of clinical symptoms (with an emphasis on gait impairment) and neuroimaging findings.650 FACTORA & LUCIANO of Monro to the maximum width of the calvarium at the same level (Fig. the authors’ group has created a classification scheme based on clinical experience to aid in determining candidacy for shunting in patients who have suspected NPH (Table 2). and are considered to have features of NPH. and metabolism but have not added accuracy to diagnosis or determining responsiveness to shunting. it does not identify the cause of the enlargement and. along with xenon CT blood flow studies (with use of acetazolamide) and MRI have been useful in experimental settings to study the pathology of NPH. Evans ratiodthe ratio of the maximum width of the anterior horns of the lateral ventricles to the maximum width of the calvarium at the same level of the foramen of Monro. cannot define hydrocephalus without other criteria or differentiate ventriculomegaly resulting from NPH or atrophy. These techniques. 1). imaging consistent with true hydrocephalus without significant atrophy and without confounding comorbidities. In an ideal situation.3 defines ventriculomegaly.

nonresponders may be spared the surgical risk. Patients who do not have radiologic evidence of ventriculomegaly (whether or not they have symptoms suggestive of NPH [quadrant III] or atypical presentations [quadrant IV]) should not be considered to have NPH. as when cognitive deficits overshadow or precede gait deficits. without significant gait impairment. however.NORMAL PRESSURE HYDROCEPHALUS 651 Table 2 Categorization of patients for shunting. Given the unclear long-term benefits of shunting in these patients. patients are not ideal candidates for shunting. the authors proceed with further diagnostic evaluation to include a trial of CSF drainage (described later) via a lumbar puncture (LP) or extended lumbar catheter drainage. It helps to determine the presence of ventricular reflux and to detect poor absorption of CSF (especially in cases of obstructions in the ventricle or cisternal spaces) but has been . they may be considered for further testing for NPH. The authors do not routinely recommend a trial of CSF drainage or a shunt for patients in quadrant III or IV. possible shunting IV Not Candidate for shunt have considered this ‘‘ideal’’ patient (quadrant I) as a candidate for shunting without further testing. In the absence of a true gold standard for the diagnosis of NPH. to quantify clinical response before a permanent shunt is placed. If these patients have imaging consistent with hydrocephalus (quadrant II). raising doubt over the diagnosis of NPH. symptoms are atypical. a substantial response to CSF drainage becomes the criterion standard we use to define NPH response to a shunt procedure. probable shunting III Further evaluation needed. or comorbidities cloud the diagnosis or limit long-term benefits of shunting. Patients may have only one element of Adam’s triad. Ancillary testing Much research has been conducted using various tests to increase the diagnostic accuracy of NPH and to determine whether or not placement of a shunt likely is effective in patients who have suspected NPH. the diagnosis of NPH is left uncertain. which is introduced via LP and allowed to distribute within the ventricular and subarachnoid system (over 24–48 hours). for example. such as a trial CSF drainage. NPH very unlikely Ventriculomegaly absent II Consider drainage trial. In many situations. by quadrants. In this way. based on results of clinical examination and neuroimaging Ventriculomegaly present Symptoms NPH symptoms present NPH symptoms absent I Proceed with drainage trial. Cisternography involves imaging of the ventricular system using a radiolabeled isotope. In other patients. however. In the authors’ experience. some of these patients demonstrate significant improvements after drainage despite atypical presentation or confounding comorbidities.

Additionally. A calculated value greater than 18 units indicates a problem with absorption and is useful in diagnosing hydrocephalus. however. The great number of techniques studied and used by neurosurgeons reflects the lack of diagnostic accuracy or predictive value of an individual test. thereby limiting its application in clinical practice. as the true prevalence rate of NPH is unknown. limits the predictive value of this procedure in community practice. There are wide ranges in sensitivity and specificity of these tests (Table 3). with assessment of gait and cognitive abilities before and after drainage to measure symptom improvement.652 FACTORA & LUCIANO relatively insensitive in detecting NPH. the definition of improvement in this test also varies. many patients who have NPH may be missed with this single test. Additionally. without knowledge of the true prevalence of NPH and a gold standard comparison for accurate diagnosis. there is an increased risk of complications (eg. removal of large volumes of CSF (10 mL/h for 3 days) has been useful in aiding in the diagnosis of NPH and in determining if shunting is likely to improve the symptoms of NPH (gait in particular). Performance of multiple LPs may increase sensitivity. . these estimates may be limited in their clinical usefulness by selection bias. Additionally. Typically. In the authors’ experience. Performance of this procedure can be done in an outpatient setting. Potential selection bias. headache) associated with prolonged catheter drainage. Calculation of the outflow resistance helps to determine a patient’s response to shunt placement. Sensitivity and specificity of this test in detecting significant changes range from 50% to 100% and 60% to 100%. The CSF infusion test is used to measure impedance of flow of CSF absorption pathways via infusion of artificial CSF to the subarachnoid space. The CSF ‘‘tap-test’’ involves removal of 40 to 50 mL of CSF. but there is significant discomfort for patients. Continuous intracranial pressure monitoring is used to reveal the presence of increased pressure spikes (B waves) during sleep that are considered pathognomonic for NPH. Continuous lumbar drainage involves removal of up to 720 mL of CSF over 72 hours using an indwelling percutaneous catheter. comparisons of gait and cognitive function are made before and after the external lumbar drainage to provide objective evidence of a clinically significant response. evidence is limited for its usefulness in predicting shunt responsiveness. denoting the underlying difficulty in obtaining large cohorts for study. Because of its invasive nature and controversies in interpretation of findings. significant technical expertise is needed to perform the test. Although noted improvements may be helpful in diagnosing NPH. it is of limited application in clinical practice. external lumbar drainage when performed in patients in quadrant I (described previously) is the test most highly predictive of a good outcome after a shunt. As with previously noted studies. Despite its value. Cisternography has not been useful in predicting response to shunting in NPH. respectively [14]. In clinical studies.

has been used in limited cases. The value of supplemental prognostic tests for the preoperative assessment of idiopathic normal-pressure hydrocephalus. Klinge P. Although third ventriculostomy success in cases of obstructive NPH is more established.NORMAL PRESSURE HYDROCEPHALUS 653 Table 3 Characteristics of ancillary studies used in diagnosis of normal pressure hydrocephalus and determination of benefit for surgical intervention Cisternography Sensitivity Specificity Positive predictive value Negative predictive value n/a n/a n/a Cerebrospinal fluid outflow resistance 57%–100% 44%–92% 75%–92% Cerebrospinal fluid tap test 26%–62% 33%–100% 73%–100% External lumbar drainage 50%–100% 60%–100% 80%–100% n/a 27%–92% 23%–42% 36%–100% Abbreviation: n/a. One or two scalp incisions and a small . Data from Marmarou A BM. spinal catheters and shunt into the right atrium via the facial or subclavian vein also are possible. Shunt surgery usually takes approximately 30 minutes and involves one overnight stay in the hospital. For the past 4 decades. although it is used less frequently because of perceived lower reliability. Neurology 2005. Fig. a carbonic anhydrase inhibitor and diuretic. Later. drainage into the peritoneal cavity became the favored method (ventriculoperitoneal shunting). CSF usually is drained from the ventricle into the peritoneal cavity. including NPH. Neuroendoscopic third ventriculostomy. Although shunting has remained the same in principle for the past 4 decades. Shunting CSF from the lumbar spine to the peritoneal cavity also is described for NPH. not available.57(Suppl 2):S2-17–28. Acetazolamide. there have been improvements in implantation method and systems. Treatment Pharmacotherapy has not been successful in the treatment of hydrocephalus or for NPH. The first shunts in the treatment of hydrocephalus drained CSF into the venous system or right atrium (ventriculoatrial shunting). CSF shunting through an implanted catheter and valve system has been the mainstay in treatment in most forms of hydrocephalus. a surgical treatment making a fenestration directly between the third ventricle and the subarchnoid space without any implanted hardware. As with other forms of hydrocephalus. its use for the more common communicating NPH remains uncertain. et al. Relkin N. reduces the production of CSF by 30% to 50% and sometimes is used to palliate cases of mild hydrocephalus but usually cannot be used for definitive treatment [15–20]. primarily because of fears of complications from vascular catheter access. 2 helps illustrate the effects of shunting on NPH.

note the large collections of CSF in the sulcal spaces. (B) Brain with NPH in same patient after shunt placement (right lateral ventricle)dsulcal collections of fluid are reduced significantly after shunting. the amount of CSF drainage can be titrated. the abdominal incision is 3 to 5 mm and chances of adhesions and infection are reduced greatly. (A) Brain of a patient who had NHP before shunt placement. they should be treated with a procedure called endoscopic third ventriculostomy (ETV). The simplest first-generation valves offered a fixed resistance to CSF flow to avoid overdrainage. which is implanted under the scalp. Patients who have long-standing aqueductal stenosis. much in the same way a dose of medication may be adjusted for maximum benefit.654 FACTORA & LUCIANO Fig. where there is a blockage in CSF flow between the third and fourth ventricle. and if symptoms are consistent with chronic hydrocephalus. These valves have undergone many changes and many kinds are available. In this procedure. . 2. The shunt system includes a one-way resistance valve. abdominal incision are required. The special case of NPH symptoms caused by chronic obstruction is worth discussion. Most recently. because its diagnosis is different and these patients may be treated surgically but without a shunt. may present in mid or late adulthood with NPH symptoms. With modern laparoscopic placement. These systems allow optimization of drainage in each person without further surgically invasive procedures. generations of valves offered features to prevent uneven surges of drainage with changes in position and activities. a neuroendoscope is introduced into the lateral ventricle via a right frontal burr hole and extended down to the floor of the third ventricle. Later. In this way. valves that can be adjusted after implantation have been developed. A LP is not useful or advisable in the diagnostic workup.

where ancillary tests are used to select shunt responsive patients. not causing a general systemic illness but instead causing poor healing or shunt dysfunction. or any other form of general systemic disease or progressive disease that limits life expectancy. Most often these infections are insidious and chronic from slow growing Staphylococcus epidermidis or Propionibacterium acnes species adherent to the shunt system. draining the optimal . the entire shunt system must be explanted and replaced after antibiotic treatment. greater improvements in clinical outcomes are seen.NORMAL PRESSURE HYDROCEPHALUS 655 where a hole is made allowing fluid escape [21]. The reported rate of clinical improvement seen in gait. advances in shunting methods and materials. providing the shunt continues its drainage. and urinary incontinence after shunting varies from as low as 25% to over 90%. In the authors’ experience. and definitions of success. uncontrolled hypertension. diabetes. If the system becomes infected. The rate of intracerebral hemorrhage with catheter placement is approximately 1% to 2%. Successful treatment also depends on continuing medical and surgical follow-up to ensure proper shunt function (ie. with severe morbidity or death in 6% to 8% [22]. With neuropsychologic testing. Improvements in cognition. In addition. Surgical risks are reduced by the short length of the surgery and the use of small incisions. Modern shunt catheters with antibiotic impregnation hold promise for reduced incidence of infection. is recommended. Urologic symptoms can improve dramatically. After shunt placement. generally. such has cardiac disease. Subdural hematoma from overdrainage occurs less than 5% of the time. Although gait improvement is observed after CSF trial drainage. with benefits persisting indefinitely for years. The historic variability in success reflects differences in patient selection. No implanted device is needed. however. Although there is no strict age cutoff after which patients are considered too old for the procedure. the CSF drainage trial has improved the process of patient selection for a shunt and. based only on symptoms and large ventricles. therefore. these cognitive changes are variable and less impressive than the gait improvements. contraindications are based on comorbidity. improvement in gait is the most frequent observable benefit. Outcomes: benefits and risks Any surgery in the elderly population has risks. In more recent series. Early studies have quoted risks as high as 30% to 40% in shunting. These risks justify preoperative testing to ensure optimal patient selection. is reported to be approximately 8% to 10%. restoring urinary continence and improving patient quality of life. memory. it may continue to improve gradually in the months after shunting. higher failure rates in earlier studies likely reflect less diagnostic precision in selecting patients for shunting. although ETV fenestrations may fail. and alertness often are reported by patients. cognition. Shunt infection in hydrocephalus.

The special clinical problem of symptomatic hydrocephalus with normal cerebrospinal fluid pressure. with gait impairment. possibly. . however. Observations on cerebrospinal fluid hydrodynamics. stroke. References [1] Hakim S. such as cerebrvascular disease.2:307–27. and a CSF tap may be indicated. meticulous surgical implantation. If patients’ symptoms recur or headaches or new symptoms develop. If ventriculomegaly exists. Alzheimer’s disease) or systemic diseases (eg. NPH still may be considered even in the context of other symptoms and comorbidities (such as spinal or vascular disease) and some of these patients also may undergo CSF drainage trial to evaluate potential improvement (quadrant II). and ventriculomegaly as identified on either CT or MRI (ie. Without careful follow-up of shunted patients. cognitive slowing and urinary urgency and incontinence. Advancements in the technique and materials of CSF shunting and improvements in follow-up and postoperative CSF drainage have increased the possibility of benefit after treatment and reduced complications. The diagnosis of NPH may be reinforced with ancillary tests. CSF flow adjustments. does not eliminate the possibility of NPH but has a negative impact on the benefits of ventricular shunting. J Neurol Sci 1965. may be useful in reinforcement of the diagnosis but may have little additional impact on diagnostic accuracy. Essential to the diagnosis of NPH are ventriculomegaly and gait disturbance. intracranial pressure monitoring. results in a definite shortening of quality of life in the elderly population. quadrant I patients). Optimal treatment of NPH requires vigilant patient selection. and revisions may be required periodically. including MRI with cine CSF flow study. The existence of other neurologic problems. where the removal of several hundred milliliters of CSF over an extended period of time may be performed optimally through a lumbar drain. whereas cognitive and urinary problems also are seen often and. Adams RD. and careful follow-up with optimization. unexplained by spinal disease or other progressive neurologic disorder. Referral for an evaluation by an experienced neurosurgeon should be considered strongly if symptoms include gait impairment. gains made in elderly patients’ function through appropriate shunting may be lost in the successive years by the shunt failure the development of other cerebral diseases (eg. Follow-up imaging. CT or MRI should be performed. Summary NPH is a chronic adult hydrocephalus characterized by gait deficit and. It is a disease of CSF circulation and parenchymal changes. constitute Adam’s triad. Other tests. The failure to identify and treat these patients. shunt taps. CSF infusion studies.656 FACTORA & LUCIANO amount). and cisternograms. intracerebrovascular disease).

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